Gastroesophageal Reflux Disease(GERD)Ch.42 pp. 931-935

GERDReflux of stomach acid into

esophagus◦Causes mucosal damage

Possible causes◦Incompetent LES◦Obesity◦Cigarette and cigar smoking◦Hiatal hernia

GERD

What clinical manifestations may the pt. with GERD exhibit?

GERDComplicationsEsophagitis

◦Can lead to strictures, scar tissue, and dysphagia

Esophageal ulcerationsBarrett’s esophagus

◦Precancerous lesionRespiratory complicationsDental erosion

GERDDiagnostic StudiesHistory and PhysicalUpper GI endoscopy with biopsyEsophagram (barium swallow)Motility StudiespH monitoringRadionuclide studies

GERDCollaborative CareLifestyle modificationNutritional TherapyDrug therapySurgery

GERDCollaborative CareLifestyle modification

◦Avoid triggers◦Weight reduction◦Smoking cessation◦Manage stress

GERDCollaborative Care Nutritional Therapy

◦ Avoid foods /items that decrease LES pressure (Table 42-7) Alcohol Anticholinergics Chocolate Fatty foods Nicotine Peppermint

◦ Avoid milk◦ Small frequent meals◦ Increase saliva production◦ Avoid late evening meals◦ Fluid between rather than with meals◦ Avoid foods that irritate esophagus◦ Positioning

GERDCollaborative CareDrug Therapy

◦Goals of drug therapy Decrease volume and acidity of reflux Improve LES function Increase esophageal clearance Protect esophageal mucosa

GERDCollaborative Care Drug Therapy

◦ Proton Pump Inhibitors (eg. Prevacid, Prilosec, Protonix, Nexium)

◦ Histamine (H2)- Receptor Blockers (eg. Tagamet, Pepcid, Zantac)

◦ Prokinetic Agents (eg. Reglan)

◦ Antiulcer, Protectants (eg. Carafate)

◦ Cholinergics (eg. Urecholine)

◦ Antacids (eg. Amphojel, Tums, Alka-Seltzer, Maalox, Mylanta)

◦ Prostaglandins (eg. Cytotec)

GERD Collaborative Care

Surgical Therapy◦Nissen and Toupet fundoplications

Fundus of stomach wrapped around lower portion of esophagus

◦LINX reflux management system Titanium beads with magnetic core implanted into LES

Endoscopic Therapy◦Endoscopic mucosal resection◦Photodynamic therapy◦Cryotherapy◦Radiofrequency ablation

GERDNursing ManagementPt Teaching

◦ Elevation of head of bed 30 degrees◦ Not lying down for 2–3 hours after eating◦ Avoidance of late-night eating◦ Evaluating effectiveness of medications◦ Observing for side effects of medications◦ Avoidance of factors that cause reflux

Stop smoking Avoid alcohol and caffeine Avoid acidic foods

◦ Stress reduction techniques◦ Weight reduction, if appropriate◦ Small, frequent meals

GERDNursing ManagementPostop Care

◦Prevent respiratory complications◦Maintain F & E balance◦Prevent infection◦Respiratory assessment◦Deep breathing◦Pain management◦Meds to prevent N & V◦Fluids (peristalsis present) then gradually

progress to solids◦Avoid gas producing foods

APPENDICITISCh.43 pp.973-974

APPENDICITISETIOLOGY & PATHOPHYSIOLOGY Most common cause of RLQ pain

Opening of the appendix is obstructed or blocked

Initial obstruction associated with:Fecaliths (most common cause)

APPENDICITISETIOLOGY & PATHOPHYSIOLOGY Perforation

PeritonitisElevation in temperature Increased pulse

MCBURNEY’S POINT

APPENDICITISDiagnostics Collaborative Care

History and Physical Laboratory findings

CBC including WBC with diff.

Serum electrolytes Abdominal paracentesis

and culture of fluid Imaging Diagnostics

Abdominal X-ray Ultrasound CT scan

Appendectomy Antibiotics Fluid replacement

APPENDICITISNONSURGICAL MANAGEMENT Hospitalized and examined by HCP

Keep pt NPO

DO NOT…..Give laxative or enema

Post-op managementEarly ambulationAdvance diet as tolerated

PeritonitisCh.43 pp.974-975

PeritonitisEtiology & Pathophysiology

Life threatening

Bacterial contamination of peritoneum

Massive fluid shifts

PeritonitisClinical Manifestations

What clinical manifestations may the pt. with peritonitis exhibit?

PeritonitisDIAGNOSTIC STUDIES

CBC WBC Peritoneal aspiration Abdominal X-ray Ultrasound CT scans

COLLABORATIVE CARE Antibiotics NG suction Analgesics IV fluids Surgery

PeritonitisNursing Management

What findings should the nurse assess for in the pt. with suspected peritonitis?

Nursing Diagnosis Acute pain Risk for deficient fluid volume Anxiety

PeritonitisNursing Management

Planning: Pt. goals Resolve inflammation Relieve abdominal pain No complications Normal nutritional status

PeritonitisNursing Management Nursing Implementation

IV access▪ Fluid replacement▪ Antibiotics

Pain management Pt. may be positioned with knees flexed Decrease anxiety Monitor I & O Monitor VS Antiemetics NPO NG tube Oxygen therapy Post-op care for laparotomy